Healthcare Provider Details

I. General information

NPI: 1881945475
Provider Name (Legal Business Name): LIGHTHOUSE PEDIATRIC & AFTER HOURS CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2012
Last Update Date: 09/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 SPRINGRIDGE RD
CLINTON MS
39056-5633
US

IV. Provider business mailing address

501 SPRINGRIDGE RD
CLINTON MS
39056-5633
US

V. Phone/Fax

Practice location:
  • Phone: 601-488-4171
  • Fax: 601-488-4175
Mailing address:
  • Phone: 601-488-4171
  • Fax: 601-488-4175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number16949
License Number StateMS

VIII. Authorized Official

Name: DR. TAMMY LASHELLE SIMS
Title or Position: CEO
Credential: M.D.
Phone: 601-488-4171